Painful callosities in a young boy

A 9-year-old boy was first evaluated at 4 years of age with fragile hair since the first months of life (Figure 1), thin nails, onychomadesis, and koilonychia. By the age of 2, he had plantar erythema in areas of pressure that evolved with hyperkeratosis and intense local pain. His mother had had similar lesions on the plantar surface since childhood. Physical examination showed rounded hyperkeratotic plaques at plantar pressure sites with an erythematous halo (Figure 2). The hairs were examined under optic microscopy and evidenced trichorrhexis nodosa (Figure 3). He was started on acitretin, and the hyperkeratosis and pain decreased initially, but he needed an increase in dosage at follow-up because the pain intensified. A pediatric orthopedist evaluated him and recommended orthopedic insoles and physiotherapy, but there was no improvement in the pain. At follow-up, the hyperkeratosis had worsened and progressed to the entire anterior portion of the soles and part of the heels (Figure 4), with severe pain even with the use of topical and systemic antiinflammatories, analgesics, and opioids.